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A M . J . DRUG ALCOHOL ABUSE, 18(3), pp. 235-246 (1992)
Crack Cocaine Use and Sexual Behavior among Psychiatric Inpatients Anthony Kim, M.D. Marc Galanter,* M.D. Ricardo Castaneda, M.D. Harold Lifshutz, Ph.D. Hugo Franco, M.D. Division of Alcoholism and Drug Abuse Department of Psychiatry New York University School of Medicine 550 First Avenue, New York, New York 10016
ABSTRACT Rises in both crack cocaine use and incidence of sexually transmitted diseases have been recently reported. In this study, we investigated the relalionship between crack cocaine abuse and sexual behavior in 50 psychiatric inpatients. The relationship between crack use and sexual behavior is a very complicated one. influenced by many variables such as the dose of crack used. the user’s preexisting sexuality, gender, and psychiatric illness. Results indicated that while most of the subjects developed sexual disinterest and dysfunction with prolonged crack cocaine use. some of them became more sexually promiscuous and consequently contracted more sexually transmitted diseases. The implications of these findings regarding transmission of HIV among crack cocaine users are discussed.
INTRODUCTION Recently there has been a dramatic rise in syphilis and other sexually transmitted diseases (STD) among heterosexuals [ 11. Epidemiologists at the Centers for *To whom correspondence should be addressed.
235
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Disease Control (CDC) have traced a correlation between increasing use of crack cocaine and an increase in STDs throughout the United States. Because sexual services are frequently bartered for crack cocaine, whatever STDs happen to be the most prevalent are spread among crack abusers. CDC officials are concerned about the possible effect of the STD increase on the prevalence of acquired immune deficiency syndrome (AIDS) among the general population [2]. In a recent study of the drug use history and human immunodeficiency virus 0 status of female prostitutes, it was found that those who abused crack and other cocaine but have not used intravenous (IV) drugs had at least as high a level of HIV seropositivity as IV drug abusers [3]. The investigators suggested that crack cocaine abusers who are not prostitutes also may be at high risk of HIV infection. It is important to study the sexual lives of crack users so that we can better estimate the health risks to which they are exposed. More importantly, if crack users understand the relationship between crack use and STD, they may be motivated to change certain aspects of their drug use and sexual behaviors. Finally, we may be able to plan public policy measures to help prevent new STD epidemics in crack users. In this study we investigated sexual desire, number of sexual partners, and reported incidence of STDs among crack cocaine abusing psychiatric inpatients. We also investigated the relationships among phychiatric diagnosis, gender, crack cocaine use, and sexual behavior.
METHOD The subjects in this study were 50 male and female psychiatric inpatients at Bellevue Hospital who fulfilled the DSM-111-R criteria for cocaine dependence. Patients were admitted because of dangerousness to self or to others. Inpatients on the general psychiatric wards who were identified by the ward psychiatrists to have a history of crack cocaine abuse were assessed for inclusion in the study. Subjects who considered crack cocaine as their primary drug of abuse were selected for participation. Subjects who were dependent on other substances in addition to crack were included as long as they considered crack as their primary drug of abuse. Subjects who did not consider crack cocaine as their primary drug of abuse were excluded. Those patients who gave a history of prostitution before the onset of crack abuse were excluded. Approximately 25 % of the sample assessed were excluded by L.e above criteria. Evaluation for crack dependence and other psychiatric illnesses was made by one of the investigators (A.K.), a psychiatrist, using a clinical interview, review
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of the patient’s chart, and consultation with the treating unit psychiatrist. Those patients who were acutely psychotic on initial screening were interviewed at least 2 weeks after admission, when they were stabilized and able to cooperate with the interviewer. All patients were interviewed within 4 weeks after admission. Participation in the study was voluntary, and the participants were asked to respond as frankly as possible. Patients were told that their answers would not be shared with the unit staff, and that only group data would be reported. Out of 53 patients included, three declined to complete the structured interview. The instrument used for the structured interview included 6 1 multiple-choice or numerical response items, codable for computerized scoring. It included demographic data, including sex, ethnicity, marital status, employment, income, housing status, and education. The instrument assessed crack use and included questions on the duration of use and the quantity and frequency of use in the previous month. Also included were questions on frequency of other drug use in the previous month and items on past psychiatric treatment and substance abuse treatment. A history of treatment for STD before and since crack use was obtained based on the patients’ recollection of what they were told by the treating physicians. A question regarding the use of condoms in the last month of crack cocaine use was included. Questions on sexual behavior were divided into three sections corresponding to three different periods (the last month of crack use, the first month of crack use, and the month prior to crack use). Included in each period were questions on the number of sexual partners. Responses to questions about level of sexual desire, level of sexual satisfaction, and intensity of orgasm were coded on a 5-point Likert scale (1 = none, 5 = very high). For the periods of the last and the first month of crack use, the immediate aphrodisiac effect of crack was coded on a 3-point scale (1 = decreased sexual desire, 2 = no effect, 3 = increased).
Statistical Analysis t-Tests were used to compare the duration, quantity, and frequency of crack cocaine use to variables such as sexual desire, number of sexual partners, reported incidence of STD, psychiatric diagnosis, and gender. The independent variables were the time periods of crack cocaine use, namely the month prior to crack use, first month of crack use, and last month of crack use. The dependent variables were sexual desire, sexual satisfaction, intensity of orgasm, and number of sexual partners. t-Tests were used to analyze the relationships among the independent and the dependent variables. Furthermore, the
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sample was divided into two subgroups, those who were sexually active in the last month of crack use and those who were sexually inactive. Using t-tests, these two subgroups were then compared with respect to crack cocaine use pattern, STD, and the other variables relating to sexual behavior. The data on reported STD treatment history were presented according to a specific STD and whether the disease was contracted before or since crack cocaine use. t-Tests were used to compare the number of STDs contracted before and after onset of crack use. In order to gauge the accuracy of the self-reports of STD treatments, current Venereal Disease Research Laboratory (VDRL) test results were compared to reported syphilis treatment data using a chi-square test. t-Tests were used to compare VDRL status to the total number of STD before and since crack use. Also included are the data on condom use. Using t-tests, we compared condom use to crack cocaine use pattern, psychiatric diagnosis, gender, STD data, VDRL status, and number of sexual partners. Regarding psychiatric history and diagnosis, the sample was divided into two subgroups, schizophrenic and nonschizophrenic. The two subgroups were compared with regard to crack cocaine use pattern, various aspects of sexual behavior, number of sexual partners, and STD data using t-tests and chi-square analysis. Finally, the sample was divided into men and women, and these two groups were compared on all of the above-mentioned variables using the same statistical tests.
RESULTS Demographic Characteristics Patients were predominantly male (N = 38, 76%) with a mean age of 31.2 (SD = 7.5) years. Twenty-nine patients (58%) were Black, 13 (26%) were Hispanic, 7 (14%) were White, and 1 (2%) was categorized as other. Socioeconomic status was indicative of a low-functioning population in terms of housing, employment, and ability to maintain a stable relationship, as 21 patients (42%) were homeless, 43 (86%) were unemployed, and 39 (78%) were either single or divorced.
Drug Use Pattern The mean duration of crack use was 29.0 f 15.8 months. The quantity of crack cocaine used in the previous month in terms of the dollar amount per week
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was $559.1 f 507.7. Within the past 30 days the group used crack 21.9 + 9.1 days. Crack cocaine use duration, quantity, and frequency were chosen as independent variables to examine sexual desire, sexual satisfaction, number of sexual partners, and STD, and no significant relationships were found. Crack quantity was significantly related to psychiatric diagnosis and gender. This result is discussed below. With regard to use of other drugs in the past 30 days, the three most commonly co-abused drugs were alcohol (I 1.7 days in the past 30 days 12.3), marijuana (5.9 f 9.7), and nonintravenous use of opiates (4.3 f 9.2). Intravenous use of drugs was uncommon (0.8 day +_ 3.3).
*
Sexual Behavior The time periods of crack use (i.e., the month prior to crack use, the first month of crack use, and the last month of crack use) were used as independent variables to examine sexual desire, sexual satisfaction, intensity of orgasm, and number of sexual partners. Sexual desire, sexual satisfaction, and intensity of orgasm all decreased significantly in the last month of crack use compared to the month prior to onset of use (see Table 1). The differences in the above three variables between first month and last month of use also showed a decreasing trend but were not statistically significant. Another datum that suggests crack cocaine does not enhance sexual function is that, among men, 24 patients (63%)said they could not achieve an erection while high on crack. In response to the question regarding condom use in the last month of crack use, 20 patients (40%) said the question was not applicable to them because they did not engage in any type of sexual intercourse during that period. Therefore, the subjects were divided into two subgroups, those who were sexually active in the last month ( N = 30, 60%) and those who were sexually inactive (N = 20, 40%). For the active subgroup the number of sexual partners was significantly higher in the last month of crack use compared to the month prior to use, while the exact opposite was true for the inactive group (see Table I). The fact that the inactive group’s mean number of sexual partners is 0.55 rather than zero is due to inconsistency in some of the subjects’ responses; while answering the condom use question, some indicated that they were sexually abstinent in the last month of condom use, but in a later part of the interview admitted to having had some sexual intercourse.
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Table 1. Variables Associated with Reported Sexual Behavior
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Month prior to crack use
Last month of crack use
Comparison
N
Mean
SD
Mean
SD
t
Pa
Sexual desire
50
3.50
1.22
2.80
1.18
3.18
,003
Sexual satisfaction
50
3.36
1.19
2.46
1.22
4.24
,001
Intensity of orgasm
50
3.32
1.28
2.88
1.49
2.20
.04
Number of sexual partners
50
3.04
5.13
4.52
7.06
1.50
N.S.b
partners active in thelast month
30
3.93
6.27
7.17
8.11
2.10
.05
Number of sexual partners inactive in the last month
20
1.70
2.16
0.55
0.69
2.15
.05
Number of sexual
'Significance level of difference, r-test, one-tailed. bN.S. = Not significant at the p < .05 level.
Comparing the sexually active subgroup to the sexually inactive one, there was no significant difference in the duration, quantity, or frequency of crack use. There was no difference between the subgroups in the level of sexual desire. Although there was no significant difference in the frequency of STD treatment before crack use, the sexually active group had significantly higher STD treat1.05, c = 3.76, p < ment frequency since crack use (0.15 f 0.37 vs 0.93 .001). Another way the two groups differed was that, for men, the active group was more likely to be able to have erection while high on crack ( x 2 = 6.85, p < .04).There was no difference in gender distribution.
*
Reported STD Treatment History With regard to STD treatment either before or since crack use, gonorrhea was the most frequently reported STD (N = 23, 46%), followed by syphilis (N = 10,20%),genital herpes (N = 3,6%), and other STD (N = 5 , l O X ) . With regard to STD treatment only since crack use, however, syphilis was the most frequently reported (N = 8, 16%), followed by gonorrhea (N = 5 , lo%),herpes (N = 1, 2%), and other STD (N = 3, 6%).
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In order to gauge the validity of the subjects’ reports of STD episodes, we examined their current VDRL status. Seven subjects (14%) were positive, 36 (72%) were negative, and 7 (14%) were untested. For the 43 subjects with known VDRL results, we compared their VDRL status to reported syphilis treatment data and found there was a significant relationship ( x 2 = 11.52, p < .001). Furthermore, when we compared the VDRL positive subjects to the VDRL negative subjects with respect to incidence of STD since crack use there was significant difference (1.57 & 0.98 vs 0.44 f 0.84, t = 3.16, p < .005)but not with regard to incidence of STD before crack use. Hence the VDRL results seem to support validity of the reports of treatment for syphilis and lend internal consistency to the STD data as a whole. When asked if condoms were ever used during sexual intercourse in the last month of crack use, 20 subjects answered “yes,” 10 answered “no,” and 20 answered “not applicable due to absence of sexual intercourse during the period. For the 30 who were sexually active in the last month, we analyzed the relationship between the use of condoms and the quantity, frequency, and duration of crack cocaine use and found no significant relationship. We also examined the relationship between the use of condom and the reported incidence of STD and VDRL status and found no significant relationship. There was also no significant relationship between condom use and psychiatric diagnosis. There was, however, a significant association between condom use and the number of sexual partners; those who used condoms were more likely to have had a higher number of sexual partners (9.30 k 9.23 vs 2.90 f 1.29, t = 2.10, p < .05). Those who used condoms were also more likely to be women than men ( x 2 = 8.06, p < .02). ”
Psychiatric Diagnosis Diagnostic evaluations revealed 7 patients (14%) with schizophrenia, 13 patients (26%) with mood disorder, one patient (2%) with organic brain syndrome, and 29 patients (58%) with personality disorder. An examination of the subjects’ history of previous psychiatric treatment revealed that these subjects had chronic courses with frequent treatments. Forty patients (80%)had prior psychiatric treatment, and 3 1 patients (62 %) were previously treated with psychotropic medication. The mean number of previous psychiatric hospitalizations was 4. l & 7.6. We compared schizophrenics with nonschizophrenics (i.e., mood disorders and personality disorders). There was no significant difference in the duration or frequency of crack use, but the nonschizophrenics tended to use higher quantities of crack ($313 per week vs $612, p = .074). There were no significant
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differences in sexual desire, in the immediate aphrodisiac effect of crack, in intensity of orgasm, in sexual satisfaction, or in ability to have an erection while high on crack. There was no significant difference in the number of steady sexual partners, but the nonschizophrenic group had a significantly higher number of sexual partners (1.43 f 2.57 vs 5.10 f 7.52, t = 2.42, p < .03). Although there was no difference in STD treatment frequency before crack use, nonschizophrenics had significantly higher STD treatment frequency since crack use (0.14 f 0.38 vs 0.71 f 0.97, t = 2.76, p < .02).
Gender No significant differences in crack use duration, quantity, or frequency were found between men and women. Women reported significantly lower sexual desire and intensity of orgasm prior to crack use and in the first month of crack use. In the first month of crack use, women also reported significantly less aphrodisiac effect from crack than men (1.47 vs 0.75, t = 2.69, p < .02). However, in the last month of crack use there was no significant difference between men and women in the level of sexual desire, the intensity of orgasm, or in the immediate aphrodisiac effect of crack. In the last month of crack use, women had significantly more sexual partners than men (2.3 f 3.34 vs 11.58 f 10.63, t = 2.98, p < .02). Although women had no more STD treatment frequency before crack use, they had significantly higher STD treatment frequency since crack use (0.42 k 0.72 vs 1.25 f 1.22, t = 2.24, p < .05).
DISCUSSION There are many myths concerning cocaine and sex but few scientific studies on the issue. In studying such a sensitive topic as sexual behavior, obtaining reliable data was challenging. There were two major limitations in this study. First was its retrospective nature which limited its reliability as the respondents were asked to recollect events that took place some months ago. Also, the personal nature of the topic might have caused some respondents to modify their answers. However, these respondents participated voluntarily and confidentially, and this most likely increased the possibility of valid responses. Often the respondents themselves were quite curious about how crack use affected their sexual behavior and were eager to participate in the study. A second limitation was the unusual nature of the subjects of this study. These subjects did not represent the crack
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abusing population at large. The fact that they were being treated at an inpatient psychiatric setting meant that they represented the psychiatrically disabled portion of the crack-abusing population. The high rate of unemployment, homelessness, and social isolation showed that the respondents were particularly low-functioning. Their crack habit profiles revealed that they were severely and chronically addicted. Therefore, the findings from this study should not be generalized except with great caution.
Sexual Desire The results of the present investigation revealed that sexual desire decreased significantly with prolonged use of crack. However, Siegel conducted a longitudinal study of social-recreational users who consumed 1 to 4 g of cocaine intranasally per month and found that their subjects experienced sexual stimulation without significant sexual dysfunction [4]. In a later study by Siegel of 32 cocaine free-base smokers, 13 reported no sexual activity during periods of freebase use, and 20 of 23 males experienced situational impotency [ 5 ] . When the spouses and sexual partners of these users were interviewed, virtually all cocaine smokers were experiencing episodes of sexual disinterest. The difference between the results of these two studies may be due to dose-effect; cocaine snorters probably had lower blood levels of cocaine than free-base smokers [ 6 ] .In our study the respondents frequently attributed a dose-related aphrodisiac effect to crack. In collateral interviews many male subjects reported that if they were to smoke two or three vials, they would be sexually aroused and able to have erection. But if they were to smoke more, they would become impotent and become so involved with crack itself that they would lose interest in performing sexually. Not only did crack reduce sexual desire, but it also severely reduced sexual performance and ability to enjoy sex. Most men complained that they were rendered impotent by crack and that they could hardly feel the orgasm when they climaxed. Because many men were impotent while using crack, the most frequent route of sexual activity was oral. Crack affected men and women differently with regard to sexual desire. Whereas men tended to voice positive feelings about sex, women showed either apathy or antipathy toward sex. Women reported significantly lower sexual desire than men prior to crack use and in the first month of crack use. In the first month of crack use, women also reported less often than men feeling the aphrodisiac effect from crack. This was especially true for four women who said that they became prostitutes since using crack; they voiced strong dislike for sex and denied
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any aphrodisiac effect from crack. Consistent with a prior report [7], we have observed that men seemed to use crack to obtain sexual favors while women seemed to use sex to obtain crack. The gender difference in drug acquisition patterns may partly account for the gender difference in sexual stimulation attributed to crack; women often reported feeling exploited and degraded and, therefore, are not able to enjoy the sexual experience. The difference in aphrodisiac effect attributed to crack between men and women may also be pharmacological in basis. A difference in the stimulant drug’s effect on sexual desire between sexes has been reported by Pam [8]. Also of interest is the issue of who experiences sexual stimulation from a drug and who does not. In this study the sexually active group had a higher number of sexual partners than the inactive group even prior to the onset of crack cocaine use (see Table 1). In fact, with prolonged crack use, the sexually active group became significantly more promiscuous while the sexually inactive group showed marked sexual inhibition. This finding is in agreement with two other studies that examined the relationship between amphetamine use and sexual behavior. Bell and Trethowan questioned patients who had a history of amphetamine addiction about the effect of addiction on sexuality [9]. They found that those who were sexually inhibited tended to say that amphetamines had no effect or caused a decrease in sexuality while those who were sexually active were sexually stimulated by amphetamine use. Angrist and Gershon conducted a similar study with amphetamine-abusing patients [101. They concluded that amphetamines can dramatically heighten preexisting sexual drive and yet did not appear to create such drive where little or none preceded the drug use. Hence it appears that a drug’s effect on one’s sexuality is far from uniform and depends largely on the person’s preexisting sexuality.
Number of Sexual Partners It is significant that as sexual desire decreased with prolonged crack use, the number of sexual partners did not necessarily decrease. In fact, a majority of the sample, while reporting a marked reduction in sexual desire and satisfaction, had a significantly higher number of sexual partners in the last month of crack use. One way to understand this seeming contradiction is by looking at the setting in which crack abuse takes place. As indicated in Williams’ naturalistic study, in cocaine dens the respondents reported buying and using crack in the presence of other crack users where sexual activity was a natural part of crack-using behavior [l 11. The relationship between crack use and sexual behavior seems to be based
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less on the pharmacological or physiological effect of the crack than on the environment in which crack is obtained and used.
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Reported STD Treatments Our study repeatedly showed that those who were more sexually promiscuous reported more STD treatments. When we compared those who were sexually active in the last month to those who were sexually inactive, the sexually active group had a significantly higher frequency of reported STD treatment since crack use but not before crack use. Sunilarly, the nonschizophrenic group, which was significantly more sexually active than the schizophrenic group, had significantly higher reported STD treatment since crack use, but not before crack use. Women were significantly more sexually active than men and had a significantly higher frequency of STD treatment since crack use but not before. Thus crack users who were sexually active seemed to be at higher risk of contracting STDs. Syphilis was the most frequent STD for which treatment was reported since onset of crack use. Relevant to this is the finding in a study at an STD clinic in Baltimore, Maryland, that among heterosexuals without traditional risk factors, HIV infection was significantly associated with a history of syphilis [ 121. Since STDs which cause genital ulceration are believed to facilitate HIV sexual transmission, crack use can become an important factor in the transmission of HIV among inner city heterosexuals.
Psychiatric Diagnosis Psychiatric diagnosis seemed to influence crack’s effect on sexual behavior. Schizophrenic respondents, while showing no significant difference in sexual desire, feeling the aphrodisiac effect of crack, or having the ability to have an erection, were significantly less likely to be sexually active than nonschizophrenic respondents. This could be explained by schizophrenic’s general tendency to be socially isolated. This does not suggest, however, that schizophrenic patients in general are sexually inactive and therefore are at less risk for STD. Carmen and Brady, for example, write “chronic mentally ill may be at high risk of contracting HIV because their cognitive impairment, poor judgment, affective instability, and impulsiveness are likely to result in behaviors that include unsafe sexual practices and drug use” [ 131. These authors argue that stereotypes of the mentally ill as asexual have had dangerous consequences, namely the absence of sex education and AIDS prevention as an integral part of treatment.
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In conclusion, the present study shows that the relationship between crack use and sexual behavior is a very complicated one and is influenced by many variables such as the dose of crack used, the user’s preexisting sexuality, the gender, and the psychiatric illness. We found that although most of the subjects developed sexual disinterest and dysfunction with prolonged crack use, some of them became more sexually promiscuous and consequently contracted more STD’s. This last finding may have important implications for transmission of HIV among the crackabusing psychiatric population in inner cities. Further studies involving a larger and more representative sample of a general crack-abusing population should be conducted to better understand the relationship between crack use, sexual behavior, and STD.
ACKNOWLEDGMENTS This project was conducted with support from grants from the New York Task Force on Integrated Projects (No. CoooO38) and the Scaife Family Foundation.
REFERENCES
[31 141
151
171
[81
PI
Goldsmith, M., Sex tied to drugs = STD spread, JAMA 14:2009 (1988). Quinn, T., The epidemiology of the human immunodeficiency virus, Ann. Emerg. Med. 31225-232 (1990). Sterk, C., Cocaine and HIV seropositivity, Lancer 5: 1052-1053 (1988). Siegel, R. K., Long-term effects of recreational cocaine use; A four year study, in Cocaine 1980 (F. Jeri, ed.), Pacific Press, Lima, Peru, 1980. Siegel, R. K . , Cocaine and sexual dysfunction: The curse of mama coca, J . Psychoactive Drugs 14:71-74 (1982). Paly, D., et al., Cocaine plasma levels after cocaine paste smoking, in Cocaine 1980 (F. Jeri, ed.),Pacific Press, Lima, Peru, 1980. Morningstar, P., and Chitwood, D., How women and men get cocaine: Sex-role stereotypes and acquisition patterns, J. Psychoactive Drugs 19(2):135-142 (1987). Parr, D., Sexual aspects of drug abuse in narcotic addicts, Br. J. Addict. 71:261-268 (1976). Bell, D., and Trethowan, W., Amphetamine addiction and disturbed sexuality, Arch. Gen. Psychiatry 4:100-104 (1961). Angrist, B., and Gershon, S., Clinical effects of amphetamine and L-DOPA on sexuality and aggression, Compr. Psychiarry 17:7 15-722 (1976). Williams, T.,Cocaine Kids, Addison-Wesley, Reading, Massachusetts, 1989. Quinn, T., et al., Human immunodeficiency virus infection among patients attending clinics for sexually transmitted diseases, New Engi. J. Med. 318: 197-203 (1988). Carmen, E., and Brady, S., AIDS risk and prevention for the chronic mentally ill, Hosp. Community Psychiafry 41(6):652-657 (1990).
A M . J . DRUG ALCOHOL ABUSE, 18(3), pp. 235-246 (1992)
Crack Cocaine Use and Sexual Behavior among Psychiatric Inpatients Anthony Kim, M.D. Marc Galanter,* M.D. Ricardo Castaneda, M.D. Harold Lifshutz, Ph.D. Hugo Franco, M.D. Division of Alcoholism and Drug Abuse Department of Psychiatry New York University School of Medicine 550 First Avenue, New York, New York 10016
ABSTRACT Rises in both crack cocaine use and incidence of sexually transmitted diseases have been recently reported. In this study, we investigated the relalionship between crack cocaine abuse and sexual behavior in 50 psychiatric inpatients. The relationship between crack use and sexual behavior is a very complicated one. influenced by many variables such as the dose of crack used. the user’s preexisting sexuality, gender, and psychiatric illness. Results indicated that while most of the subjects developed sexual disinterest and dysfunction with prolonged crack cocaine use. some of them became more sexually promiscuous and consequently contracted more sexually transmitted diseases. The implications of these findings regarding transmission of HIV among crack cocaine users are discussed.
INTRODUCTION Recently there has been a dramatic rise in syphilis and other sexually transmitted diseases (STD) among heterosexuals [ 11. Epidemiologists at the Centers for *To whom correspondence should be addressed.
235
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Disease Control (CDC) have traced a correlation between increasing use of crack cocaine and an increase in STDs throughout the United States. Because sexual services are frequently bartered for crack cocaine, whatever STDs happen to be the most prevalent are spread among crack abusers. CDC officials are concerned about the possible effect of the STD increase on the prevalence of acquired immune deficiency syndrome (AIDS) among the general population [2]. In a recent study of the drug use history and human immunodeficiency virus 0 status of female prostitutes, it was found that those who abused crack and other cocaine but have not used intravenous (IV) drugs had at least as high a level of HIV seropositivity as IV drug abusers [3]. The investigators suggested that crack cocaine abusers who are not prostitutes also may be at high risk of HIV infection. It is important to study the sexual lives of crack users so that we can better estimate the health risks to which they are exposed. More importantly, if crack users understand the relationship between crack use and STD, they may be motivated to change certain aspects of their drug use and sexual behaviors. Finally, we may be able to plan public policy measures to help prevent new STD epidemics in crack users. In this study we investigated sexual desire, number of sexual partners, and reported incidence of STDs among crack cocaine abusing psychiatric inpatients. We also investigated the relationships among phychiatric diagnosis, gender, crack cocaine use, and sexual behavior.
METHOD The subjects in this study were 50 male and female psychiatric inpatients at Bellevue Hospital who fulfilled the DSM-111-R criteria for cocaine dependence. Patients were admitted because of dangerousness to self or to others. Inpatients on the general psychiatric wards who were identified by the ward psychiatrists to have a history of crack cocaine abuse were assessed for inclusion in the study. Subjects who considered crack cocaine as their primary drug of abuse were selected for participation. Subjects who were dependent on other substances in addition to crack were included as long as they considered crack as their primary drug of abuse. Subjects who did not consider crack cocaine as their primary drug of abuse were excluded. Those patients who gave a history of prostitution before the onset of crack abuse were excluded. Approximately 25 % of the sample assessed were excluded by L.e above criteria. Evaluation for crack dependence and other psychiatric illnesses was made by one of the investigators (A.K.), a psychiatrist, using a clinical interview, review
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of the patient’s chart, and consultation with the treating unit psychiatrist. Those patients who were acutely psychotic on initial screening were interviewed at least 2 weeks after admission, when they were stabilized and able to cooperate with the interviewer. All patients were interviewed within 4 weeks after admission. Participation in the study was voluntary, and the participants were asked to respond as frankly as possible. Patients were told that their answers would not be shared with the unit staff, and that only group data would be reported. Out of 53 patients included, three declined to complete the structured interview. The instrument used for the structured interview included 6 1 multiple-choice or numerical response items, codable for computerized scoring. It included demographic data, including sex, ethnicity, marital status, employment, income, housing status, and education. The instrument assessed crack use and included questions on the duration of use and the quantity and frequency of use in the previous month. Also included were questions on frequency of other drug use in the previous month and items on past psychiatric treatment and substance abuse treatment. A history of treatment for STD before and since crack use was obtained based on the patients’ recollection of what they were told by the treating physicians. A question regarding the use of condoms in the last month of crack cocaine use was included. Questions on sexual behavior were divided into three sections corresponding to three different periods (the last month of crack use, the first month of crack use, and the month prior to crack use). Included in each period were questions on the number of sexual partners. Responses to questions about level of sexual desire, level of sexual satisfaction, and intensity of orgasm were coded on a 5-point Likert scale (1 = none, 5 = very high). For the periods of the last and the first month of crack use, the immediate aphrodisiac effect of crack was coded on a 3-point scale (1 = decreased sexual desire, 2 = no effect, 3 = increased).
Statistical Analysis t-Tests were used to compare the duration, quantity, and frequency of crack cocaine use to variables such as sexual desire, number of sexual partners, reported incidence of STD, psychiatric diagnosis, and gender. The independent variables were the time periods of crack cocaine use, namely the month prior to crack use, first month of crack use, and last month of crack use. The dependent variables were sexual desire, sexual satisfaction, intensity of orgasm, and number of sexual partners. t-Tests were used to analyze the relationships among the independent and the dependent variables. Furthermore, the
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sample was divided into two subgroups, those who were sexually active in the last month of crack use and those who were sexually inactive. Using t-tests, these two subgroups were then compared with respect to crack cocaine use pattern, STD, and the other variables relating to sexual behavior. The data on reported STD treatment history were presented according to a specific STD and whether the disease was contracted before or since crack cocaine use. t-Tests were used to compare the number of STDs contracted before and after onset of crack use. In order to gauge the accuracy of the self-reports of STD treatments, current Venereal Disease Research Laboratory (VDRL) test results were compared to reported syphilis treatment data using a chi-square test. t-Tests were used to compare VDRL status to the total number of STD before and since crack use. Also included are the data on condom use. Using t-tests, we compared condom use to crack cocaine use pattern, psychiatric diagnosis, gender, STD data, VDRL status, and number of sexual partners. Regarding psychiatric history and diagnosis, the sample was divided into two subgroups, schizophrenic and nonschizophrenic. The two subgroups were compared with regard to crack cocaine use pattern, various aspects of sexual behavior, number of sexual partners, and STD data using t-tests and chi-square analysis. Finally, the sample was divided into men and women, and these two groups were compared on all of the above-mentioned variables using the same statistical tests.
RESULTS Demographic Characteristics Patients were predominantly male (N = 38, 76%) with a mean age of 31.2 (SD = 7.5) years. Twenty-nine patients (58%) were Black, 13 (26%) were Hispanic, 7 (14%) were White, and 1 (2%) was categorized as other. Socioeconomic status was indicative of a low-functioning population in terms of housing, employment, and ability to maintain a stable relationship, as 21 patients (42%) were homeless, 43 (86%) were unemployed, and 39 (78%) were either single or divorced.
Drug Use Pattern The mean duration of crack use was 29.0 f 15.8 months. The quantity of crack cocaine used in the previous month in terms of the dollar amount per week
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was $559.1 f 507.7. Within the past 30 days the group used crack 21.9 + 9.1 days. Crack cocaine use duration, quantity, and frequency were chosen as independent variables to examine sexual desire, sexual satisfaction, number of sexual partners, and STD, and no significant relationships were found. Crack quantity was significantly related to psychiatric diagnosis and gender. This result is discussed below. With regard to use of other drugs in the past 30 days, the three most commonly co-abused drugs were alcohol (I 1.7 days in the past 30 days 12.3), marijuana (5.9 f 9.7), and nonintravenous use of opiates (4.3 f 9.2). Intravenous use of drugs was uncommon (0.8 day +_ 3.3).
*
Sexual Behavior The time periods of crack use (i.e., the month prior to crack use, the first month of crack use, and the last month of crack use) were used as independent variables to examine sexual desire, sexual satisfaction, intensity of orgasm, and number of sexual partners. Sexual desire, sexual satisfaction, and intensity of orgasm all decreased significantly in the last month of crack use compared to the month prior to onset of use (see Table 1). The differences in the above three variables between first month and last month of use also showed a decreasing trend but were not statistically significant. Another datum that suggests crack cocaine does not enhance sexual function is that, among men, 24 patients (63%)said they could not achieve an erection while high on crack. In response to the question regarding condom use in the last month of crack use, 20 patients (40%) said the question was not applicable to them because they did not engage in any type of sexual intercourse during that period. Therefore, the subjects were divided into two subgroups, those who were sexually active in the last month ( N = 30, 60%) and those who were sexually inactive (N = 20, 40%). For the active subgroup the number of sexual partners was significantly higher in the last month of crack use compared to the month prior to use, while the exact opposite was true for the inactive group (see Table I). The fact that the inactive group’s mean number of sexual partners is 0.55 rather than zero is due to inconsistency in some of the subjects’ responses; while answering the condom use question, some indicated that they were sexually abstinent in the last month of condom use, but in a later part of the interview admitted to having had some sexual intercourse.
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Table 1. Variables Associated with Reported Sexual Behavior
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Month prior to crack use
Last month of crack use
Comparison
N
Mean
SD
Mean
SD
t
Pa
Sexual desire
50
3.50
1.22
2.80
1.18
3.18
,003
Sexual satisfaction
50
3.36
1.19
2.46
1.22
4.24
,001
Intensity of orgasm
50
3.32
1.28
2.88
1.49
2.20
.04
Number of sexual partners
50
3.04
5.13
4.52
7.06
1.50
N.S.b
partners active in thelast month
30
3.93
6.27
7.17
8.11
2.10
.05
Number of sexual partners inactive in the last month
20
1.70
2.16
0.55
0.69
2.15
.05
Number of sexual
'Significance level of difference, r-test, one-tailed. bN.S. = Not significant at the p < .05 level.
Comparing the sexually active subgroup to the sexually inactive one, there was no significant difference in the duration, quantity, or frequency of crack use. There was no difference between the subgroups in the level of sexual desire. Although there was no significant difference in the frequency of STD treatment before crack use, the sexually active group had significantly higher STD treat1.05, c = 3.76, p < ment frequency since crack use (0.15 f 0.37 vs 0.93 .001). Another way the two groups differed was that, for men, the active group was more likely to be able to have erection while high on crack ( x 2 = 6.85, p < .04).There was no difference in gender distribution.
*
Reported STD Treatment History With regard to STD treatment either before or since crack use, gonorrhea was the most frequently reported STD (N = 23, 46%), followed by syphilis (N = 10,20%),genital herpes (N = 3,6%), and other STD (N = 5 , l O X ) . With regard to STD treatment only since crack use, however, syphilis was the most frequently reported (N = 8, 16%), followed by gonorrhea (N = 5 , lo%),herpes (N = 1, 2%), and other STD (N = 3, 6%).
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In order to gauge the validity of the subjects’ reports of STD episodes, we examined their current VDRL status. Seven subjects (14%) were positive, 36 (72%) were negative, and 7 (14%) were untested. For the 43 subjects with known VDRL results, we compared their VDRL status to reported syphilis treatment data and found there was a significant relationship ( x 2 = 11.52, p < .001). Furthermore, when we compared the VDRL positive subjects to the VDRL negative subjects with respect to incidence of STD since crack use there was significant difference (1.57 & 0.98 vs 0.44 f 0.84, t = 3.16, p < .005)but not with regard to incidence of STD before crack use. Hence the VDRL results seem to support validity of the reports of treatment for syphilis and lend internal consistency to the STD data as a whole. When asked if condoms were ever used during sexual intercourse in the last month of crack use, 20 subjects answered “yes,” 10 answered “no,” and 20 answered “not applicable due to absence of sexual intercourse during the period. For the 30 who were sexually active in the last month, we analyzed the relationship between the use of condoms and the quantity, frequency, and duration of crack cocaine use and found no significant relationship. We also examined the relationship between the use of condom and the reported incidence of STD and VDRL status and found no significant relationship. There was also no significant relationship between condom use and psychiatric diagnosis. There was, however, a significant association between condom use and the number of sexual partners; those who used condoms were more likely to have had a higher number of sexual partners (9.30 k 9.23 vs 2.90 f 1.29, t = 2.10, p < .05). Those who used condoms were also more likely to be women than men ( x 2 = 8.06, p < .02). ”
Psychiatric Diagnosis Diagnostic evaluations revealed 7 patients (14%) with schizophrenia, 13 patients (26%) with mood disorder, one patient (2%) with organic brain syndrome, and 29 patients (58%) with personality disorder. An examination of the subjects’ history of previous psychiatric treatment revealed that these subjects had chronic courses with frequent treatments. Forty patients (80%)had prior psychiatric treatment, and 3 1 patients (62 %) were previously treated with psychotropic medication. The mean number of previous psychiatric hospitalizations was 4. l & 7.6. We compared schizophrenics with nonschizophrenics (i.e., mood disorders and personality disorders). There was no significant difference in the duration or frequency of crack use, but the nonschizophrenics tended to use higher quantities of crack ($313 per week vs $612, p = .074). There were no significant
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differences in sexual desire, in the immediate aphrodisiac effect of crack, in intensity of orgasm, in sexual satisfaction, or in ability to have an erection while high on crack. There was no significant difference in the number of steady sexual partners, but the nonschizophrenic group had a significantly higher number of sexual partners (1.43 f 2.57 vs 5.10 f 7.52, t = 2.42, p < .03). Although there was no difference in STD treatment frequency before crack use, nonschizophrenics had significantly higher STD treatment frequency since crack use (0.14 f 0.38 vs 0.71 f 0.97, t = 2.76, p < .02).
Gender No significant differences in crack use duration, quantity, or frequency were found between men and women. Women reported significantly lower sexual desire and intensity of orgasm prior to crack use and in the first month of crack use. In the first month of crack use, women also reported significantly less aphrodisiac effect from crack than men (1.47 vs 0.75, t = 2.69, p < .02). However, in the last month of crack use there was no significant difference between men and women in the level of sexual desire, the intensity of orgasm, or in the immediate aphrodisiac effect of crack. In the last month of crack use, women had significantly more sexual partners than men (2.3 f 3.34 vs 11.58 f 10.63, t = 2.98, p < .02). Although women had no more STD treatment frequency before crack use, they had significantly higher STD treatment frequency since crack use (0.42 k 0.72 vs 1.25 f 1.22, t = 2.24, p < .05).
DISCUSSION There are many myths concerning cocaine and sex but few scientific studies on the issue. In studying such a sensitive topic as sexual behavior, obtaining reliable data was challenging. There were two major limitations in this study. First was its retrospective nature which limited its reliability as the respondents were asked to recollect events that took place some months ago. Also, the personal nature of the topic might have caused some respondents to modify their answers. However, these respondents participated voluntarily and confidentially, and this most likely increased the possibility of valid responses. Often the respondents themselves were quite curious about how crack use affected their sexual behavior and were eager to participate in the study. A second limitation was the unusual nature of the subjects of this study. These subjects did not represent the crack
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abusing population at large. The fact that they were being treated at an inpatient psychiatric setting meant that they represented the psychiatrically disabled portion of the crack-abusing population. The high rate of unemployment, homelessness, and social isolation showed that the respondents were particularly low-functioning. Their crack habit profiles revealed that they were severely and chronically addicted. Therefore, the findings from this study should not be generalized except with great caution.
Sexual Desire The results of the present investigation revealed that sexual desire decreased significantly with prolonged use of crack. However, Siegel conducted a longitudinal study of social-recreational users who consumed 1 to 4 g of cocaine intranasally per month and found that their subjects experienced sexual stimulation without significant sexual dysfunction [4]. In a later study by Siegel of 32 cocaine free-base smokers, 13 reported no sexual activity during periods of freebase use, and 20 of 23 males experienced situational impotency [ 5 ] . When the spouses and sexual partners of these users were interviewed, virtually all cocaine smokers were experiencing episodes of sexual disinterest. The difference between the results of these two studies may be due to dose-effect; cocaine snorters probably had lower blood levels of cocaine than free-base smokers [ 6 ] .In our study the respondents frequently attributed a dose-related aphrodisiac effect to crack. In collateral interviews many male subjects reported that if they were to smoke two or three vials, they would be sexually aroused and able to have erection. But if they were to smoke more, they would become impotent and become so involved with crack itself that they would lose interest in performing sexually. Not only did crack reduce sexual desire, but it also severely reduced sexual performance and ability to enjoy sex. Most men complained that they were rendered impotent by crack and that they could hardly feel the orgasm when they climaxed. Because many men were impotent while using crack, the most frequent route of sexual activity was oral. Crack affected men and women differently with regard to sexual desire. Whereas men tended to voice positive feelings about sex, women showed either apathy or antipathy toward sex. Women reported significantly lower sexual desire than men prior to crack use and in the first month of crack use. In the first month of crack use, women also reported less often than men feeling the aphrodisiac effect from crack. This was especially true for four women who said that they became prostitutes since using crack; they voiced strong dislike for sex and denied
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any aphrodisiac effect from crack. Consistent with a prior report [7], we have observed that men seemed to use crack to obtain sexual favors while women seemed to use sex to obtain crack. The gender difference in drug acquisition patterns may partly account for the gender difference in sexual stimulation attributed to crack; women often reported feeling exploited and degraded and, therefore, are not able to enjoy the sexual experience. The difference in aphrodisiac effect attributed to crack between men and women may also be pharmacological in basis. A difference in the stimulant drug’s effect on sexual desire between sexes has been reported by Pam [8]. Also of interest is the issue of who experiences sexual stimulation from a drug and who does not. In this study the sexually active group had a higher number of sexual partners than the inactive group even prior to the onset of crack cocaine use (see Table 1). In fact, with prolonged crack use, the sexually active group became significantly more promiscuous while the sexually inactive group showed marked sexual inhibition. This finding is in agreement with two other studies that examined the relationship between amphetamine use and sexual behavior. Bell and Trethowan questioned patients who had a history of amphetamine addiction about the effect of addiction on sexuality [9]. They found that those who were sexually inhibited tended to say that amphetamines had no effect or caused a decrease in sexuality while those who were sexually active were sexually stimulated by amphetamine use. Angrist and Gershon conducted a similar study with amphetamine-abusing patients [101. They concluded that amphetamines can dramatically heighten preexisting sexual drive and yet did not appear to create such drive where little or none preceded the drug use. Hence it appears that a drug’s effect on one’s sexuality is far from uniform and depends largely on the person’s preexisting sexuality.
Number of Sexual Partners It is significant that as sexual desire decreased with prolonged crack use, the number of sexual partners did not necessarily decrease. In fact, a majority of the sample, while reporting a marked reduction in sexual desire and satisfaction, had a significantly higher number of sexual partners in the last month of crack use. One way to understand this seeming contradiction is by looking at the setting in which crack abuse takes place. As indicated in Williams’ naturalistic study, in cocaine dens the respondents reported buying and using crack in the presence of other crack users where sexual activity was a natural part of crack-using behavior [l 11. The relationship between crack use and sexual behavior seems to be based
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less on the pharmacological or physiological effect of the crack than on the environment in which crack is obtained and used.
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Reported STD Treatments Our study repeatedly showed that those who were more sexually promiscuous reported more STD treatments. When we compared those who were sexually active in the last month to those who were sexually inactive, the sexually active group had a significantly higher frequency of reported STD treatment since crack use but not before crack use. Sunilarly, the nonschizophrenic group, which was significantly more sexually active than the schizophrenic group, had significantly higher reported STD treatment since crack use, but not before crack use. Women were significantly more sexually active than men and had a significantly higher frequency of STD treatment since crack use but not before. Thus crack users who were sexually active seemed to be at higher risk of contracting STDs. Syphilis was the most frequent STD for which treatment was reported since onset of crack use. Relevant to this is the finding in a study at an STD clinic in Baltimore, Maryland, that among heterosexuals without traditional risk factors, HIV infection was significantly associated with a history of syphilis [ 121. Since STDs which cause genital ulceration are believed to facilitate HIV sexual transmission, crack use can become an important factor in the transmission of HIV among inner city heterosexuals.
Psychiatric Diagnosis Psychiatric diagnosis seemed to influence crack’s effect on sexual behavior. Schizophrenic respondents, while showing no significant difference in sexual desire, feeling the aphrodisiac effect of crack, or having the ability to have an erection, were significantly less likely to be sexually active than nonschizophrenic respondents. This could be explained by schizophrenic’s general tendency to be socially isolated. This does not suggest, however, that schizophrenic patients in general are sexually inactive and therefore are at less risk for STD. Carmen and Brady, for example, write “chronic mentally ill may be at high risk of contracting HIV because their cognitive impairment, poor judgment, affective instability, and impulsiveness are likely to result in behaviors that include unsafe sexual practices and drug use” [ 131. These authors argue that stereotypes of the mentally ill as asexual have had dangerous consequences, namely the absence of sex education and AIDS prevention as an integral part of treatment.
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In conclusion, the present study shows that the relationship between crack use and sexual behavior is a very complicated one and is influenced by many variables such as the dose of crack used, the user’s preexisting sexuality, the gender, and the psychiatric illness. We found that although most of the subjects developed sexual disinterest and dysfunction with prolonged crack use, some of them became more sexually promiscuous and consequently contracted more STD’s. This last finding may have important implications for transmission of HIV among the crackabusing psychiatric population in inner cities. Further studies involving a larger and more representative sample of a general crack-abusing population should be conducted to better understand the relationship between crack use, sexual behavior, and STD.
ACKNOWLEDGMENTS This project was conducted with support from grants from the New York Task Force on Integrated Projects (No. CoooO38) and the Scaife Family Foundation.
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